Applying for Medi-Cal

Introduction

The Medi-Cal program is jointly administered by the federal government and the State of California through the Department of Health and Human Services. The federal government permits California to:

  • establish its own eligibility standards
  • determine the type, amount, duration and scope of services provided
  • set the rate of payment for services
  • administer the program

California allows the 58 counties to implement the program and each county manages the program through its local social services agency. In Los Angeles County, The Department of Social Service (DPSS) manages the program. The DPSS allows AIDS Project Los Angeles to have a liaison for the application and education of their clients.

Who can apply?

Originally, Medi-Cal was established to guarantee, access to quality health care for families with limited resources and for the blind, aged, and disabled. Since its inception the program has been expanded to include other populations of people with limited resources and/or high cost medical needs. To be eligible for Medi-Cal, recipients must be receiving either a cash grant that provides Medi-Cal automatically as a benefit, or they must meet the assets limitation criteria of $2,000 for individuals or $3,000 for couples as well as be members of an eligible population.

There are two categories of eligible recipients: those receiving cash grants and those who are not receiving cash grants. Cash grant recipients who are approved for any of the below listed programs automatically receive Medi-Cal through their participation in the cash grant program. These cash grants are:

  • CalWorks (previously known as AFDC or TANF)
  • Supplemental Security Income (SSI)
  • Entrant Cash Assistance (ECA)
  • Refugee Cash Assistance (RCA)
  • In-Home Supportive Services

Applicants who do not receive one of the above cash grants must fall within one of the following categories in order to be eligible for Medi-Cal. To qualify an applicant must be either:

  • Blind
  • Aged (over 65)
  • Disabled
  • Pregnant
  • Under age 21
  • A member of a family who meets federal AID to Families with Dependent Children (AFDC)
  • A person receiving care in a skilled nursing facility or intermediate care facility.
  • A refugee or entrant who has been in the country for less than 8 months and does not qualify for or des not request ECA or RCA

Medical Eligibility for HIV

The vast majority of people with HIV who apply for Medi-Cal coverage claim disability. Medi-Cal uses Social Security’s definition of disability and uses the same process of disability evaluation.

This means that if Social Security has already found an applicant disabled, Medi-Cal will accept Social Security’s finding. Social Security Disability Insurance (SSDI) recipients do not have to prove disability again for Medi-Cal. SSDI recipients need only provide proof of Social Security’s finding of disability in order to meet the Medi-Cal disabled standard. Typically an award letter or the most recent SSDI Benefit statement will suffice as proof. Recipients receiving Supplemental Security Income (SSI) are automatically eligible for Medi-Cal and the Social Security Administration (SSA) will notify the state of California and the Medi-Cal information will be sent to the recipient.

Persons who wish to apply for Medi-Cal and does not have an SSA award may do so by filing a complete application along with the “Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection” (DHS 7035A). The form signed by a listened health care professional is very similar to SSA’s Medical report form #4814. The same criteria are applicable to Social Security’s medical eligibility for HIV.

Medi-Cal Coverage

Medi-Cal covers a broad range of medical services. Services include but are not limited to:

  • inpatient hospital services, including tests, surgeries, special procedures and care that is medically necessary
  • outpatient hospital services
  • physician services
  • medical and surgical dental services
  • nursing facility (NF) services for individuals aged 21 or older
  • home health care for persons eligible for nursing facility services
  • family planning services and supplies
  • rural health clinic services and any other ambulatory services offered by a rural health clinic that are otherwise covered under the state plan
  • laboratory and X-ray services
  • pediatric and family nurse practitioner services
  • federally qualified health center services and any other ambulatory services offered by a federally qualified health center that are otherwise covered under the state plan
  • nurse
  • midwife services
  • early and periodic screening, diagnosis and treatment services for individuals under age 21
  • prenatal care and delivery services for pregnant women
  • ambulatory services to individuals under age 18 and individuals entitled to institutional services
  • home health services to individuals entitled to nursing facility services
  • clinic services
  • nursing facility services for persons under age 21
  • intermediate care facility/mentally retarded services
  • optometrist services and eyeglasses
  • prescribed drugs
  • TB-related services for TB-infected persons
  • prosthetic devices
  • dental services

In general there are no limitations place on basic services provide by Medi-Cal. Some procedures, treatments or care may require advanced screening or approval. If you are unsure whether or not a specific service is covered by Medi-Cal, speak with the prescribing and/or treating physician or practitioner. Service providers who accept Medi-Cal are typically well informed about care access provisions, as well as whether or not preauthorizations are required for specific treatments and procedures.

Special Note on Prescription Medications

On November 1, 1994, California’s Medi-Cal program instituted a policy of limiting prescription medications to six prescriptions per client per month. Because there are a substantial amount of HIV drugs and cancer medications that are exempt from this limit most HIV-positive Medi-Cal recipients are not affected by this policy.

Asset Exemptions

Medi-Cal exempts certain assets and properties from the evaluation of resources. The list of exempt assets is lengthy and includes:

  • one house or any other type of residence of any values as long as the applicant claims it as their primary residence. Medi-Cal allow applicants to claim for their residences apartments, condominiums, trailers, houseboats, trucks, mobile homes, or cars if they are the applicants primary shelter.
  • business property if it is used to provide income for self support.
  • other real property if the equity in the property is less then $6,000 after encumbrances and if the property is producing income of at least 65 of its total net value. Other real property can include houses, condominiums, duplexes, or vacation homes.
  • one car of any value. Any additional cars are assessed in value and deducted from the $2,000 assets limitation.
  • the first $1,500 of value in any burial trusts or burial insurance policies. Any value in excess of the $1,500 cap is counted against the $2,000 maximum.
  • one burial plot, vault or crypt of any value
  • pre-paid irrevocable burial plans of any value
  • household goods and personal effects
  • term life insurance policies
  • IRA’s that are providing the applicant with periodic payments of interest and principle
  • Non-work related annuities are exempt if:
    • The annuity was purchased before 8/11/1993 and annuity is providing the applicant with periodic payments that include interest and principle.
    • The annuity was purchased between 8/11/1993 and 3/01/1996 and the annuity is paying periodic payments of interest and principle and it cannot be restructured.
    • If the annuity was purchased between 8/11/1993 and 3/1/1996 and can be restructured. (See the rules that apply to annuities purchased after 3/1/1996).
    • The annuity was purchased after 3/1/1996 and payments include interest and principle. Medi-Cal policy requires that these payments be structured to allow for a reasonable rate of return on the balance of the annuity. This means that annuities will only be considered exempt if it is expected that the total value of the annuity would be issued out in payments over the course of the applicant’s natural life expectancy

Share of Cost

Once an applicant is approved for Medi-Cal he or she may be assesses a share of cost. A share of cost is a monthly deductible calculated from a Medi-Cal recipient’s total income. The share of cost is payable directly to health care providers. Heath care providers include but are not limited to doctors, nurse practitioners, dentist and therapists. It is important to note that a share of cost is not a bill that is paid directly to Medi-Cal and it is not a deduction from recipients’ monthly incomes. A share of cost is simply a portion of the Medi-Cal recipient’s income that is expected to go towards the cost of his or her own health care.

Supplemental Security Income (SSI) recipients and In-Home Supportive Services (IHSS) recipients are never assessed a share of cost with Medi-Cal.

Share of cost is determined using the following calculation for unearned income. Unearned income is any money received that is not associated with an hourly wage or salary. Earned income is evaluated differently.

Medi-Cal recipients who are disabled are allowed a monthly maintenance need deduction of $600 plus an additional $20 disregard fro being disabled. This combined $620 is subtracted from the total unearned income and the reaming dollar amount equals the share of cost. For example, if an SSDI recipient earns $1020 a month their share of cost would be $400 a month. The calculation would look like this:

$1020.00
$ 600.00
$ 20.00
=$ 400.00
SSDI Income
Monthly Maintenance Need
Disability disregard
Share of cost

Share of cost can be expensive, especially if a client has a high disability income. Luckily the Aged & Disabled Federal Poverty Level Program (A&D FPL) as well as the AIDS Drug Assistance Program and other benefit provisions can offer assistance in managing share of cost expenses.

Aged & Disabled Federal Poverty Level Program (A&D FPL)

The A&D FPL program provides zero cost coverage to Medi-Cal recipients who meet strict financial income limitations and who are also either 65 years or older or individuals who have been found disabled by either the Social Security Administration or Medi-Cal.

The income limit for an individual is currently $1,097 and $1,524 for a couple. An additional one-time $20 disregard is also allowed.

A&D FPL is called a Federal Poverty Level (FPL) program because the income limits are figured based on the FPL guidelines. These guidelines are changed every year (announced February or March) and subsequently the income limits will also be adjusted yearly.

The A&D FPL program income limits are strictly observed but costs associate with child care, education and premiums for private health insurances can be used to lower and individual’s income.

Medi-Cal Payer

Medi-Cal will always be the provider of last resort. If one has private insurance and Medi-care, Medi-Cal will always be last to pay for coverage.

Retroactive Three Months

The time the application is submitted to the Department of Public Social Services, the client can request three months of retroactive Medi-Cal for outstanding medical coverage. The client must present the outstanding medical bills and provide the income information requested to make sure they met the income eligibility.

Appeals

Medi-Cal applicants and recipients are allowed to appeal any administrative actions taken by Medi-Cal with which they are dissatisfied. To appeal, applicants and recipients must request a state fair hearing within 90 days of receiving an unfavorable notice of action.